MEDICARE: REBECCA A BASSHAM BS, RT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	133N00000X	Nutritionist
2	174H00000X	Health Educator
3	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1114366358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA A BASSHAM BS, RT

Provider Business Mailing Address
First Line	:	2277 SWANSON AVE
Second Line	:	SUITE B
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5991
Country	:	US
Telephone Number	:	928-486-5414
Fax Number	:	928-854-0112

Provider Business Practice Location Address
First Line	:	2277 SWANSON AVE
Second Line	:	SUITE B
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5991
Country	:	US
Telephone Number	:	928-486-5414
Fax Number	:	928-854-0112

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2013
Last Update Date	:	06/20/2013

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